(BQ) Part 1 book Dermatology skills for primary care - An illustrated guide presents the following contents: Basic skills; papular, papulosquamous and papulo vesicular skin lesions; epidermal, dermal and epidermal dermal lesions; epidermal and dermal lesions, eczematous lesions and atrophies,
Dermatology Skills for Primary Care CURRENT £ CLINICAL £ PRACTICE SERIES EDITOR: NEIL S SKOLNIK, MD Dermatology Skills for Primary Care: An Illustrated Guide, DANIEL J TROZAK, DAN J TENNENHOUSE, AND JOHN J RUSSELL, 2006 Sexually Transmitted Diseases: A Practical Guide for Primary Care, ANITA NELSON AND JOANN WOODWARD, 2006 Cardiology in Family Practice: A Practical Guide for Family Practitioners, STEVE HOLLENBERG, 2006 Bronchial Asthma: A Guide for Practical Understanding and Treatment, Fifth Edition, edited by M ERIC GERSHWIN AND TIMOTHY E ALBERTSON, 2006 Type Diabetes, Pre-Diabetes, and the Metabolic Syndrome: The Primary Care Guide to Diagnosis and Management, RONALD A CODARIO, 2005 Thyroid Disease: A Case-Based and Practical Guide for Primary Care, EMANUEL O BRAMS, 2005 Chronic Pain: A Primary Care Guide to Practical Management, DAWN A MARCUS, 2005 Bone Densitometry in Clinical Practice: Application and Interpretation, Second Edition, SYDNEY LOU BONNICK, 2004 Cancer Screening: A Practical Guide for Physicians, edited by KHALID AZIZ AND GEORGE Y WU, 2001 Hypertension Medicine, edited by MICHAEL A WEBER, 2001 Allergic Diseases: Diagnosis and Treatment, 2nd Edition, edited by PHIL LIEBERMAN AND JOHN A ANDERSON, 2000 Parkinson’s Disease and Movement Disorders: Diagnosis and Treatment Guidelines for the Practicing Physician, edited by CHARLES H ADLER AND J ERIC AHLSKOG, 2000 Bone Densitometry in Clinical Practice: Application and Interpretation, SYDNEY LOU BONNICK, 1998 Sleep Disorders: Diagnosis and Treatment, edited by J STEVEN POCETA AND MERRILL M MITLER, 1998 Diseases of the Liver and Bile Ducts: A Practical Guide to Diagnosis and Treatment, edited by GEORGE Y WU AND JONATHAN ISRAEL, 1998 The Pain Management Handbook: A Concise Guide to Diagnosis and Treatment, edited by M ERIC GERSHWIN AND MAURICE E HAMILTON, 1998 Osteoporosis: Diagnostic and Therapeutic Principles, edited by CLIFFORD J ROSEN, 1996 Dermatology Skills for Primary Care An Illustrated Guide By Daniel J Trozak, MD Private Practice of Dermatology, Modesto, CA Dan J Tennenhouse, MD, JD University of California–San Francisco Medical Center, San Francisco, CA John J Russell, MD Abington Memorial Hospital, Abington, PA and Temple University School of Medicine, Philadelphia, PA © 2006 Humana Press Inc 999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 www.humanapress.com All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher All papers, comments, opinions, conclusions, or recommendations are those of the author(s), and not necessarily reflect the views of the publisher Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices The contributors herein have carefully checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication Notwithstanding, as new research, changes in government regulations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product information provided by the manufacturer of each drug for any change in dosages or for additional warnings and contraindications This is of utmost importance when the recommended drug herein is a new or infrequently used drug It is the responsibility of the treating physician to determine dosages and treatment strategies for individual patients Further it is the responsibility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice The publisher, editors, and authors are not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication This publication is printed on acid-free paper h ANSI Z39.48-1984 (American Standards Institute) Permanence of Paper for Printed Library Materials Cover design by Daniel J Trozak, MD Left Photo: Bullous Impetigo (see color photo section, Part VI) Right Photo: Vesicle/Bulla (see p 10, Fig 11) Production Editor: Robin B Weisberg For additional copies, pricing for bulk purchases, and/or information about other Humana titles, contact Humana at the above address or at any of the following numbers: Tel.: 973-256-1699; Fax: 973-256-8314; E-mail: orders@humanapr.com, or visit our Website: http://www.humanapress.com Photocopy Authorization Policy: Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by Humana Press Inc., provided that the base fee of US $30.00 per copy is paid directly to the Copyright Clearance Center at 222 Rosewood Drive, Danvers, MA 01923 For those organizations that have been granted a photocopy license from the CCC, a separate system of payment has been arranged and is acceptable to Humana Press Inc The fee code for users of the Transactional Reporting Service is: [1-58829-489-7/06 $30.00] Printed in the United States of America 10 eISBN: 1-59259-906-0 Library of Congress Cataloging-in-Publication Data Trozak, Daniel J Dermatology skills for primary care : an illustrated guide / by Daniel J Trozak, Dan J Tennenhouse, John J Russell p ; cm (Current clinical practice) Includes bibliographical references and index ISBN 1-58829-489-7 (alk paper) Skin Diseases Dermatology Primary care (Medicine) [DNLM: Skin Diseases diagnosis Skin Diseases therapy Primary Health Care methods WR 140 T864d 2005] I Tennenhouse, Dan J II Russell, John J., MD III Title IV Series RL71.T76 2005 616.5 dc22 2005012357 Series Editor’s Introduction The diagnosis and treatment of common dermatologic problems is a critical area of skill and knowledge for primary care physicians According to the US Department of Health and Human Services,1 patients present to their physicians a skin rash as their chief concern for nearly 12 million office visits each year In 73% of these office visits, patients see their internist, family physician, or pediatrician In this respect, astonishingly, primary care clinicians see far more skin disease in their offices than dermatologists Dermatology Skills for Primary Care: An Illustrated Guide advances the targeted skill and knowledge base of primary care physicians, as well as the collaboration between dermatologists and primary care physicians, by its wise choice of organization, scope, and approach Dermatology Skills for Primary Care: An Illustrated Guide by Drs Trozak, Tennenhouse, and Russell is an important addition to the dermatology literature because it has been written collaboratively by a skilled dermatologist and two excellent academic family physicians As such, the book superbly targets the depth and scope of needs of primary care practitioners in the field of dermatology Dermatology Skills for Primary Care: An Illustrated Guide is unique in its approach by opening each chapter with the clinical questions that physicians must answer in approaching patients, and then giving the history, physical examination findings, differential diagnosis, therapeutic options for treatment, and finally explicitly answering the opening questions in each chapter The book is important in scope, providing in-depth discussions of the most common skin conditions that primary care clinicians encounter If a physician knows the contents of this book, he or she will be able to competently take care of more than 90% of the dermatologic problems that are seen in a busy office practice That is an accomplishment Neil S Skolnik, MD Associate Director Family Practice Residency Program Abington Memorial Hospital Abington, PA Professor of Family and Community Medicine Temple University School of Medicine Philadelphia, PA 1Source: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Health Statistics, 2002 data Public Use data file Table 35a http://www.aafp.org/ x24579.xml (accessed May 2, 2005) v Preface Skin diseases are a very substantial part of any primary care practice Unlike most internal conditions, dermatological lesions are apparent to the patient from their inception and the progression is usually readily evident Accurate prompt diagnosis and appropriate treatment will alleviate a great deal of suffering and reinforce the patient’s confidence in the practitioner’s skills Dermatology Skills for Primary Care: An Illustrated Guide is designed to teach basic skills and to offer an inclusive approach to skin diseases so that primary practitioners can acquire the basic diagnostic and therapeutic skills used by their dermatologic colleagues Part I reviews the basic skills and tools used in dermatologic diagnosis and also discusses basic principles of topical therapy The ensuing five parts put these skills into practical scenarios and cover the treatment of specific skin conditions that are frequently encountered in everyday general medicine Although Dermatology Skills for Primary Care: An Illustrated Guide is not a comprehensive dermatologic reference, practitioners who master the skills in Part I and apply them to the 33 commonly encountered skin conditions in Parts II–VI should be able to practice very credible general dermatology Daniel J Trozak, MD Dan J Tennenhouse, MD, JD John J Russell, MD vii About the Authors Daniel J Trozak, MD, FAAD, is a graduate of the University of Michigan School of Medicine and completed his postgraduate training in dermatology at University of Oregon Health Sciences University He served as a clinical associate professor of dermatology at Stanford University from 1974 to 1992 He has been a consultant in pharmacological research to the Psoriasis Research Institute (Palo Alto, CA) and a consultant in product research to Product Investigations Inc (Conshohocken, PA) Dr Trozak has authored and co-authored publications in the areas of melanoma, contact dermatitis, delayed cutaneous hypersensitivity, neuropeptides, and psoriasis Dr Trozak has been in the private practice of dermatology in Modesto, California since 1973 and is familiar on a firsthand basis with the dermatological problems that confront primary practitioners on a daily basis Dan J Tennenhouse, MD, JD, FCLM, is a graduate of the University of Michigan School of Medicine and the University of California Hastings College of the Law Dr Tennenhouse is a nationally recognized medico-legal consultant, author, and lecturer and has 25 years experience in the practice of primary care medicine at the University of California San Francisco School of Medicine plus more than 30 years experience on the medical school faculty teaching lecture courses He is the author or co-author of more than 30 references on risk management and medical law John J Russell, MD, AAFP, is a graduate of Pennsylvania State College of Medicine and completed his postgraduate training in family medicine at Abington Memorial Hospital, Abington, Pennsylvania Since 1993, Dr Russell has served as assistant and associate director of the Abington Memorial Hospital Family Medicine Program He is a clinical associate professor of family and community medicine at Temple University School of Medicine and lectures nationally on a variety of medical subjects including asthma, hyperlipidemia, and various aspects of dermatology He serves as a contributing editor and reviewer for several primary care journals and has authored or co-authored several papers in the areas of dermatology and general medicine ix Contents Series Editor’s Introduction v Preface vii About the Authors ix Part I: Basic Skills Specific History Dermatologic Physical Examination Indicated Supporting Diagnostic Data 29 Therapy 37 References for Part I 47 Part II: Papular, Papulosquamous, and Papulo-Vesicular Skin Lesions Molluscum Contagiosum (Dimple Warts) 51 Verruca Vulgaris (Common Warts) 59 Seborrheic Dermatitis (Dandruff) 67 Pityriasis Rosea 77 Psoriasis Vulgaris 83 10 Lichen Planus 93 11 Miliaria Rubra (Prickly Heat) 101 12 Scabies 105 References for Part II 113 Part III: Epidermal, Dermal, and Epidermal/Dermal Lesions 13 Erythrasma 117 14 Tinea (Superficial Fungi, Dermatophytosis, Ringworm) 121 15 Urticaria (Urticaria Simplex, Common Hives) 135 16 Fixed Drug Eruption 147 17 Erysipelas/Cellulitis 153 18 Erythema Multiforme 161 References for Part III 169 xi xii Contents Part IV: Epidermal and Dermal Lesions, Eczematous Lesions, and Atrophies 19 Lupus Erythematosus 175 20 Toxicodendron Dermatitis (Poison Oak, Poison Ivy, Poison Sumac; Also Known as Rhus Dermatitis) 191 21 Atopic Dermatitis (Atopic Eczema, Disseminated Neurodermatitis, Besnier’s Prurigo) 199 22 Asteatotic Eczema (Xerosis, Xerotic Eczema, Eczema Craquelé, Eczema Cannalé, Eczema Hiemalis, Winter Itch) 213 23 Senile Purpura (Bateman’s Purpura) 219 24 Striae Distensae (Striae Atrophicans, Striae Gravidarum, Stretch Marks) 223 References for Part IV 231 Part V: Pigmented, Pre-Malignant, and Common Malignant Skin Lesions 25 Seborrheic Keratosis (Old Age Spots, Liver Spots) 235 26 Ephelides (Freckles) 241 27 Lentigines 245 28 Melanocytic Nevi 251 29 Malignant Melanoma 271 30 Actinic Keratosis (Solar Keratosis) 287 31 Keratoacanthoma (Molluscum Sebaceum) 293 32 Common Skin Cancers 299 References for Part V 311 Part VI: Vesiculo-Bullous and Papulo-Pustular Disorders 33 Impetigo (Impetigo Contagiosa) 317 34 Herpes Simplex Recidivans (Herpes Labialis, Cold Sores, Fever Blisters, Herpes Genitalis) 325 35 Herpes Zoster (Shingles) 335 36 Acne Vulgaris (Acne, Zits) 345 37 Rosacea (Acne Rosasea) 359 References for Part VI 367 Appendix A: Table of Primary Lesions and Related Disorders 369 Appendix B: Table of Secondary Lesions and Related Disorders 373 Color Photographs 377 Index 441 Chapter 22 / Asteatotic Eczema 215 cream bases that are more irritating than the anti-inflammatory effect of the active ingredient, and would contribute to rather than resolve this problem Supplemental Review From General History If changes and symptoms of asteatosis respond promptly to treatment, no additional investigation is indicated Generalized pruritus without changes of asteatosis, and acquired ichthyosis can be signs of underlying systemic disease If either are present without signs of asteatosis, or if an asteatotic patient continues to have severe pruritus once the dryness is corrected, then a complete history and general physical examination should be done along with a basic CBC, chemistry panel, and a thyroid function panel Further investigation should be based on findings from that examination Dermatologic Physical Exam Primary Lesions Patches of skin that appear dull, fissured, scaly, erythematous, or impetiginized (see Photos 44,45) Intervening skin that shows an accentuated dull crisscross pattern of skin markings (see Photo 44) Secondary Lesions Fine white scale (early) Coarse white scale (later) Fissures may be dry or exudative and eczematous Color of the fissures varies from pink to a deep dusky red They may contain small amounts of hemorrhage or exudate The fissures often produce a canal-like (see Photo 46) or crazypavement (see Photo 47) pattern This craquelé pattern has also been described as resembling the surface fractures on an old piece of Chinese pottery Impetiginization Distribution Microdistribution: None Macrodistribution: The lower extremities, thighs, and hips are the most common sites Axillary folds and proximal arms are next Distribution may be generalized in severe cases (see Fig 7) Configuration The canal-like and crazy-paving patterns are virtually diagnostic (see Photos 46,47) Indicated Supporting Diagnostic Data None Therapy Prevention Unless you explain to the patient and relatives the underlying etiology of the disorder, the problem will recur Bathing habits should be reviewed; the patient should be using a 216 Part IV / Epidermal, Dermal, Eczematous Lesions, Atrophies Figure 7: Macrodistribution of asteatosis mild bath bar with moisturizing ingredients Showers are less drying than tub bathing Spas and hot tubs should be discouraged Emollients and medications must be applied immediately after toweling before the skin really dries if they are to be maximally effective Explain the effect of dry heating sources, and encourage the use of a humidifier Cold-water vaporizers are an inexpensive means of raising humidity, and they are portable and safe A central humidifier attached to the furnace is ideal, but is a substantial expense Small room humidifiers work well, but again they are expensive and have ongoing upkeep costs Topical Steroids Corticoids will suppress inflammation but will not correct the underlying dryness They should be reserved strictly for the inflamed or frankly eczematous lesions You may use group VI or VII steroid creams for this purpose, and try to choose those with an emollient base These products have enough potency to correct the inflammatory changes, and Chapter 22 / Asteatotic Eczema 217 virtually no risk of secondary atrophy They should be applied to the inflammatory lesions only, and should be followed immediately with a general application of moisturizer Moisturizers Lubricants are the real therapeutic mainstay for correcting dry skin Two factors must be considered when recommending a lubricant: (1) it must correct the dryness, and (2) it must have enough patient acceptance that it will be used regularly Two effective emollients are Original Formula Eucerin® cream and Cetaphil Moisturizing Cream® These should be applied initially TID over any dermatitic sites that have just been treated with the topical corticoid As areas of asteatosis improve, the topical steroid is gradually discontinued Moisturizers must initially be applied in a general fashion two or three times daily and immediately after toweling Once asteatosis is corrected, nightly application may be sufficient Several products are available OTC that contain either an α-hydroxy acid or urea as active ingredients Both ingredients improve the water-holding capacity of the epidermis These active agents have a definite long-term beneficial effect on the appearance and function of the epidermal surface Products are available OTC containing to 10% lactic acid, and there is a cream preparation available by prescription with a 12% concentration Because these products produce some burning or stinging when applied to open lesions, they are not well tolerated initially They are best added as a single daily application under the general emollient after epidermal integrity has been restored Urea products are available OTC in 10 to 20% concentrations These should be used with caution in the early stages of treatment, as their concomitant use can greatly enhance the percutaneous absorption of some topical steroids They can be used in a fashion similar to the α-hydroxy acid preparations Conditions That May Simulate Asteatosis Nummular Eczema This common condition produces coin-like circular lesions, and in elderly patients may begin initially in an area of asteatosis Lesions are discrete and much more inflammatory than those of asteatosis Excoriation of the lesions is prominent, the surface is moist and eczematous, and the surface lacks the canal-like or craquelé pattern Initially, itching is confined to individual lesions Acquired Ichthyosis This scaling condition in its fully developed form resembles dominantly inherited ichthyosis vulgaris Thick dirty-brown scales occur over the trunk and extremities and encroach on the skin over the flexural aspects of the large joints Acquired ichthyosis is usually intensely pruritic and in the early stage may suggest changes of asteatosis It is a paraneoplastic dermatitis that may precede, follow, or coincide with an underlying malignancy Hodgkin’s disease, mycosis fungoides, other lymphomas, and visceral cancers are most commonly associated It has also been reported with HIV infection, and does not respond to the simple measures that control asteatosis Biopsy shows changes of ichthyosis vulgaris and may be helpful in distinguishing difficult cases 218 Part IV / Epidermal, Dermal, Eczematous Lesions, Atrophies ANSWERS TO CLINICAL APPLICATION QUESTIONS History Review In the early spring, a 75-five-year-old woman visits your office with a complaint of generalized itching The symptoms began in late December on local skin areas, and have progressed throughout the winter You suspect an asteatotic eczema What information from her history may help support your suspicions? Answer: a Similar midwinter episodes in the past with spontaneous improvement during the spring and summer b Frequent use of fireplaces or wood stove heaters, which lower ambient humidity in the home c A lifelong or prolonged personal history of dry skin d A history of excessive bathing or use of medication that alters skin texture e Unusual dietary practices (malnutrition) f A severe winter season with a prolonged need for indoor heating What are the primary lesions in areas of asteatotic eczema? Answer: Patches of skin that appear dull with an accentuated crisscross pattern of skin marking What are the secondary lesions seen in asteatotic eczema? Answer: a Fine white scale (early) b Coarse white scale (later) c Fissures What typical configurations strongly support your suspicions? Answer: a Canal-like fissures (eczema cannalé) b Crazy-paving fissures (eczema craquelé) This woman has minimal physical findings, and some provoking factors are evident in her history, but she fails to improve with treatment What should be done next? Answer: A complete history and physical exam, CBC, chemistry panel, thyroid function panel, and any additional laboratory or imaging studies suggested by the history and physical 23 Senile Purpura (Bateman’s Purpura) CLINICAL APPLICATION QUESTIONS A 65-year-old active sailor presents with a history of progressive bruising of the arms over the past to years Bruises now occur with such frequency and following such minor trauma that his wife is concerned about some underlying medical problem Exam reveals large bruises limited to the sun-exposed extensor surfaces of the arms, forearms, and hands The history and physical findings suggest senile (Bateman’s) purpura What additional history will support your diagnosis? What are the primary lesions of senile purpura? What are the secondary lesions of senile purpura? What is the typical configuration of senile purpura? What is the characteristic distribution of senile purpura? What is the most important treatment for this problem? APPLICATION GUIDELINES Specific History Onset Recurrent, but otherwise asymptomatic patches of bruising occur over the sunexposed surfaces of the arms, forearms, and hands in persons who have reached their sixth decade of life The incidence increases with age, and men are more frequently affected Involvement of the sun exposed extensor surfaces of the legs occurs occasionally in women Evolution of Disease Process Once established, the condition is usually chronic, unless some provoking cofactor that can be altered is operative Evolution of Skin Lesions Localization is secondary to chronic sun-induced degenerative change in the dermal connective tissues superimposed on the natural loss of connective tissue support for the small dermal vessels (a normal characteristic of aging) Skin in the involved areas is thin and wrinkled, and usually shows chronic solar exposure Even minor degrees of shear stress will rupture small dermal vessels causing irregular areas of deep-purple purpura, which will gradually resolve over a period of several days Skin fragility and easy tearing also occur From: Current Clinical Practice: Dermatology Skills for Primary Care: An Illustrated Guide D.J Trozak, D.J Tennenhouse, and J.J Russell © Humana Press, Totowa, NJ 219 220 Part IV / Epidermal, Dermal, Eczematous Lesions, Atrophies Initially the lesions resolve completely; however, in some patients chronic activity results in permanent hyperpigmentation In patients with marked fragility, white stellate scarring may develop even at sites where no overt open tear has occurred Provoking Factors Anticoagulant, aspirin, and nonsteroidal anti-inflammatory drug (NSAID) therapy can precipitate symptoms and exacerbate existing activity Chronic systemic steroid therapy can also aggravate senile purpura but will eventually affect the entire skin surface Potent topical steroids used on the affected areas will also locally increase atrophy and activity Self-Medication Self-treatment is not a problem Supplemental review from general history If findings are typical, no general review or investigation is indicated Dermatologic Physical Exam Primary Lesions Irregular patches of deep-purple purpura that not blanch with pressure Lesions vary from coin-sized to larger (see Photo 48) Secondary Lesions Hyperpigmentation (see Photos 48,49) Epidermal atrophy manifested by fine wrinkles (see Photo 48) Stellate scars in severe cases (see Photo 49) Distribution Microdistribution: None Macrodistribution: Sun-exposed dorsal surfaces of the arms, forearms, hands, and the extensor surface of the legs There is usually a sharp cutoff at the short-sleeve line on the arms (see Fig 8) Configuration None Indicated Supporting Diagnostic Data None Therapy Elimination of offending medications that suppress clotting and platelet function will reduce or temporarily eliminate symptoms Reversal of corticosteroid-induced fragility will also occur, but more slowly and not as completely Theoretically, topical 0.1% tretinoin cream applied over a prolonged period and combined with complete solar avoidance could partially reverse the process This treatment is a decision between patient and practitioner after a full discussion of the costs and effort involved Chapter 23 / Senile Purpura 221 Figure 8: Macrodistribution of senile purpura Conditions That May Simulate Senile Purpura Steroid Purpura Similar findings and symptoms occur in the skin with chronic administration of systemic steroids, and in forms of adrenal cortex hyperactivity Skin alterations are generalized, not focal, and other signs of hypercorticism are present Local applications of potent topical steroids can simulate findings of senile purpura, and the cause is distinguishable only by history ANSWERS TO CLINICAL APPLICATION QUESTIONS History Review A 65-year-old active sailor presents with a history of progressive bruising of the arms over the past to years Bruises now occur with such frequency and following such minor trauma that his wife is concerned about some underlying medical problem Exam 222 Part IV / Epidermal, Dermal, Eczematous Lesions, Atrophies reveals large bruises limited to the sun-exposed extensor surfaces of the arms, forearms, and hands The history and physical findings suggest senile (Bateman’s) purpura What additional history will support your diagnosis? Answer: a Document the relative amount of lifelong solar exposure at work and recreation The location where exposure was obtained can also be important, as latitude and elevation alter the extent of damage b Ask about associated skin fragility that is commonly present c Review provoking factors such as anticoagulant therapy, systemic steroid therapy, or use of aspirin or NSAIDs What are the primary lesions of senile purpura? Answer: Irregular patches of nonblanching purpura, coin-sized to larger What are the secondary lesions of senile purpura? Answer: a Hyperpigmentation b Epidermal atrophy c Stellate scars What is the typical configuration of senile purpura? Answer: Senile purpura has no specific configuration What is the characteristic distribution of senile purpura? Answer: a Dorsal sun-exposed surfaces of the upper extremities with sharp cutoff at the short-sleeve line b Extensor surface of the legs What is the most important treatment for this problem? Answer: Elimination and avoidance of any provoking medications will have the most immediate effect on this problem 24 Striae Distensae (Striae Atrophicans, Striae Gravidarum, Stretch Marks) INTRODUCTION Atrophic striae occur under several circumstances They are so common as to be considered physiologic during adolescence The microscopic features reveal a combination of findings showing epidermal atrophy and dermal scar formation The cause of the lesions is usually apparent from the patient’s age or by obtaining a pertinent history On rare occasions, they can be an indication of underlying adrenal cortex dysfunction CLINICAL APPLICATION QUESTIONS An obese, middle-aged, diabetic woman presents with a complaint of worsening stretch marks over the past year She gives a history of marginal blood pressure readings in the past, but has never been on medication for hypertension Exam reveals numerous wide purple-red stria beneath the breasts, in the folds of her panniculus, and on the proximal thighs just distal to the inguinal creases What underlying causes should be of concern regarding her stria? History reveals stable weight for years, no recent pregnancy, no history of systemic steroid therapy, and normal wound healing The patient was diagnosed with intertriginous monilia 12 months ago by another practitioner, and was given a refillable prescription for a potent anti-yeast/steroid cream, which she has continued to use What is the most likely cause of her stria? What laboratory data are indicated? What is the appropriate treatment? What should the patient be told regarding the appearance of her stria? APPLICATION GUIDELINES Specific History Onset Striae occur in 35 to 40% of pubescent boys and 70% of pubescent girls, with a peak incidence about age 16 years They occur more readily in patients with a history of rapid weight gain, and adolescents seem more prone to develop lesions associated with physical exercise and corticosteroid exposure From: Current Clinical Practice: Dermatology Skills for Primary Care: An Illustrated Guide D.J Trozak, D.J Tennenhouse, and J.J Russell © Humana Press, Totowa, NJ 223 224 Part IV / Epidermal, Dermal, Eczematous Lesions, Atrophies Striae gravidarum develop to some extent in up to 90% of pregnant women during mid and late gestation, and are considered physiologic Striae associated with topical steroid usage usually occur at application sites, and may occur within weeks of initiation in susceptible persons These may occur at any age Striae associated with adrenal cortical hyperactivity occur at whatever age the process becomes clinically active Evolution of Disease Process The lesions themselves are minimally symptomatic and chronic Evolution of Skin Lesions Early lesions may be edematous and irritable, but the central area quickly becomes depressed and is initially pink, bright red, or red-blue in color Striae develop in parallel rows perpendicular to the direction of stretch or stress Most lesions are cm or less in width and, as they mature, the depressed central portion turns whiter than the intervening epidermis and they become less conspicuous Striae secondary to endocrinopathy, such as Cushing’s syndrome, are wider, centrally more atrophic, more extensively distributed, and tend to retain their central discoloration Herniation of adipose tissue into the base is common These are chronic lesions that leave varying degrees of chronic disfigurement once they mature Provoking Factors Puberty Sustained and violent physical effort with stretching Rapid weight gain Pregnancy Systemic and topical corticosteroid therapy Protease inhibitors Underlying endocrinopathies of the adrenal cortex (rare) Self-Medication Self-treatment with agents such as cocoa butter and vitamin E may occasionally trigger a contact allergy In general, self-therapy is not a problem Supplemental Review From General History When striae are wider and longer than usual, or are more extensively distributed, a general history, physical examination, and screening evaluation for an underlying endocrinopathy are indicated Dermatologic Physical Exam Primary Lesions Parallel linear patches of discolored or white depressed skin (see Photo 50) Chapter 24 / Striae Distensae 225 Secondary Lesions Yellow papules of herniated adipose tissue in the base of the stretch mark beneath the epidermis Although usually primary lesions, here papules may occur as secondary lesions Distribution Microdistribution: None Macrodistribution: Striae of puberty occur on the thighs and lumbosacral regions in boys In girls, they occur on the thighs, buttocks, breasts, and upper posterior calves (see Figs 9,10) Striae of pregnancy are distributed over the lateral abdomen, hips, thighs, and breasts (see Fig 11) Striae secondary to prolonged lifting or stretching during exercise Figure 9: Macrodistribution of striae of puberty in boys 226 Part IV / Epidermal, Dermal, Eczematous Lesions, Atrophies Figure 10: Macrodistribution of striae of puberty in girls are common over the lower back and are perpendicular to the gluteal cleft (see Fig 12, Photo 50) Striae of endocrinopathy or from systemic corticoids involve similar areas but are usually individually longer, wider, and more extensive (see Photo 51) Striae induced by potent topical steroids or occlusive therapy are local at the site of application, and may be asymmetric (see Photo 52) Configuration Parallel linear lesions Striae of endocrine origin may also have a fan-like configuration Indicated Supporting Diagnostic Data When physical findings and history suggest a possible endocrinopathy, the patient should be appropriately tested The most reliable screen is a dexamethasone suppression test Alternative tests include AM and PM serum cortisol determinations, or a 24-hour urinary free cortisol Chapter 24 / Striae Distensae 227 Figure 11: Macrodistribution of striae of pregnancy Therapy Prevention When possible, warn susceptible patients about, and advise how to eliminate, provoking causes In adolescent patients, use systemic and topical corticosteroids with great caution Avoid use of the more potent fluorinated topicals, and use them sparingly over skin regions that are prone to striae formation Topical Tretinoin Uncontrolled reports of cosmetic benefit from applications of topical 0.1% tretinoin cream have been published Results are encouraging following experience with only a few patients Double-blind studies with photographic controls are needed Early experience would suggest this is worth trying, as there is no other effective treatment Tretinoin should not be used during pregnancy or breastfeeding 228 Part IV / Epidermal, Dermal, Eczematous Lesions, Atrophies Figure 12: Macrodistribution of striae secondary to lifting or stretching Conditions That May Simulate Striae Distensae None ANSWERS TO CLINICAL APPLICATION QUESTIONS History Review An obese, middle-aged, diabetic woman presents with a complaint of worsening stretch marks over the past year She gives a history of marginal blood pressure readings in the past, but has never been on medication for hypertension Exam reveals numerous wide purple-red stria beneath the breasts, in the folds of her panniculus, and on the proximal thighs just distal to the inguinal creases Chapter 24 / Striae Distensae What underlying causes should be of concern regarding her stria? Answer: a Rapid weight gain b Pregnancy c Systemic or local corticosteroid therapy d Underlying endocrinopathy, e.g., Cushing’s disease or syndrome History reveals stable weight for years, no recent pregnancy, no history of systemic steroid therapy, and normal wound healing The patient was diagnosed with intertriginous monilia 12 months ago by another practitioner, and was given a refillable prescription for a potent antiyeast/steroid cream, which she has continued to use What is the most likely cause of her stria? Answer: Iatrogenic stria from prolonged used of a potent topical corticosteroid What laboratory data are indicated? Answer: There is enough reason in this patient to warrant screens for adrenal hypersecretion, despite the history of topical corticoid usage What is the appropriate treatment? Answer: Stop the topical steroid and consider treatment with a topical retinoid What should the patient be told regarding the appearance of her stria? Answer: The stria will fade, soften, and become less noticeable They will never completely disappear 229 .. .Dermatology Skills for Primary Care CURRENT £ CLINICAL £ PRACTICE SERIES EDITOR: NEIL S SKOLNIK, MD Dermatology Skills for Primary Care: An Illustrated Guide, DANIEL J TROZAK, DAN J TENNENHOUSE,... 83 10 Lichen Planus 93 11 Miliaria Rubra (Prickly Heat) 10 1 12 Scabies 10 5 References for Part II 11 3 Part III: Epidermal, Dermal, and... physician, or pediatrician In this respect, astonishingly, primary care clinicians see far more skin disease in their offices than dermatologists Dermatology Skills for Primary Care: An Illustrated